Cite as: Goel V. Cancer pain and opioid management. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra110126.014.

Cancer treatment has entered a new era; yet our approach to the management of cancer pain is largely static. The question is no longer simply whether opioids are indicated for an individual patient — it is how they can be aptly fit into the health care system’s delivery toolbox to improve patients’ quality of life. Several health care system–level questions arise when designing cancer pain management programs. Do these health care systems have processes and workflows to educate patients on the full spectrum of multimodal options — including non-pharmacological approaches — before an opioid is prescribed? When opioids are initiated for acute cancer pain, are there processes in place so that patients understand safe use and expected duration, and have realistic goals? Do health care system–level workflows evaluate treatment efficacy and side effects, recognizing that many patients suppress symptom reports for fear of losing their only known option? Are there care pathways to guide patients through tapering, to communicate clearly when the clinical trajectory shifts from acute cancer pain to chronic pain management, and to redefine treatment goals accordingly? Across most cancer care settings, the answer is too often no.

The Landscape Has Changed — Health Care Delivery Systems Have Not

As of January 1, 2025, approximately 18.6 million people in the United States were living with a history of cancer, a number projected to exceed 22 million by 2035.¹ We are facing an increasing population of cancer survivors due to earlier detection and enhanced therapeutic options, and a higher burden of cancer-related pain (CRP) due to the adverse effects of cancer treatments. Despite a decade of evolution in CRP management guidelines, our management of acute pain and chronic survivorship pain remains profoundly inadequate.^2,3

The clinical trajectory is clear: We have moved from the opioid-centric pain management of 2016 to the multimodal pain management mandate of 2023.^4-6 There is little agreement between different guidelines for multimodal regimens for CRP. For example, the National Comprehensive Cancer Network (NCCN) directs us to consider non-opioids and adjuvant therapies for mild pain, while the Society for Integrative Oncology and the American Society of Clinical Oncology elevate acupuncture and integrative strategies to the same tier as pharmacotherapy.^7,8 For patients with active, progressive disease and moderate-to-severe pain, opioids remain the mainstay of pharmacologic therapy.⁸ Despite the shift toward multimodal pain management, the reality on the ground tells a different story: Routine pain assessment and systematic adoption of multimodal therapies remain inadequate, while growing reluctance to prescribe opioids has left patients with cancer pain undertreated and paying the price.^6,9,10

Toll of the “Prescription Vacuum”

We must confront the data. Between 2013 and 2017, the national opioid-prescribing rate declined by 20.7% among oncologists, while gabapentin prescribing rose.¹¹ Among Medicare decedents with poor-prognosis cancers, the proportion receiving any opioid near the end of life fell 15.5%, and long-acting opioid prescriptions fell 36.5% between 2007 and 2017, while pain-related emergency department visits rose 50.8%.¹² At a tertiary cancer center, the median opioid dose prescribed by oncologists for patients referred for cancer pain fell fivefold between 2016 and 2021.¹³ This is not merely judicious prescribing; it is a systemic retreat. Even in older adults with advanced, poor-prognosis cancer, opioid access has steadily declined — a 23.5% drop in typical opioid prescribing after the 2016 Centers for Disease Control and Prevention guideline — accompanied by a 24.9% rise in gabapentinoid prescribing among older adults with any cancer.¹⁴ We have swapped evidence-based analgesia for “safety surrogates” that offer limited efficacy for cancer pain while increasing the risk of cognitive impairment and falls — a hazard formalized in the 2023 American Geriatrics Society Beers Criteria, which identify gabapentin as potentially inappropriate in older adults with a history of falls or fractures and flag concurrent opioid–gabapentinoid use as an interaction to avoid because of severe sedation, respiratory depression, and death.^15,16

As cancer pain management specialists, we see the result: a “gabapentinoid swap” that satisfies a regulatory checkbox but leaves the patient in a cycle of stigma, guilt, and unnecessary suffering. Patients now report a toxic triad of stigma, guilt, and self-dose-reduction — behaviors that manufacture unnecessary suffering in a population already facing mortality.¹⁷ While the 2026 NCCN guidelines and contemporary interventional guidelines increasingly champion assessment-guided multimodal care, including interventional blocks, integrative therapies, and neuromodulation, there is a stark implementation gap. For a patient in a geographically dispersed health system or in a rural area, “multimodal” is often synonymous with “unavailable.”^18,19

Prescription patterns have changed, but the health care delivery infrastructure around them has not evolved. We have created a two-track guideline system — non-opioid “safe surrogate” pharmacotherapy and multimodal pain management — without a corresponding improvement in health care delivery systems. The result is a clinical no-man’s-land. Oncologists focus on disease-directed therapy. Primary care physicians and pain management physicians alike are reluctant to touch opioid prescribing. And the patient, falling through the gap between the two, suffers in silence.

The Symptom Assessment Failure

The foundation of any pain management or opioid use disorder (OUD) management strategy is symptom assessment, and the data reveal systematic failure. Across 17 cancer centers in the United States, 30%–50% of patients with breast and colon cancer did not report discussing or receiving desired help from their health care providers for pain management.¹² Among 31,866 cancer patients screened for core symptoms, one-third had clinically relevant fatigue, and 45%–69% of those with one clinically relevant symptom had three or more additional symptoms.²⁰ Patients with pre-existing mental illness — the population most predisposed to co-occurring OUD — were less likely to receive symptom screening than the general cancer population.^21,22 When symptoms are not elicited or assessed, they cannot be managed adequately. When pain is not treated, the risk of OUD development or opioid relapse escalates.

Cancer and OUD: The Scope of the Problem and Consensus on Management

OUD and opioid misuse are no longer peripheral in oncology. As survivors live longer with opioid exposure, the overlap has become common. Understanding its true scope and the emerging management consensus is essential to identifying where our delivery systems fall short.

The Scope of the Problem

At the population level, national survey data are the most conservative. Among United States adults with a lifetime cancer diagnosis in the National Survey on Drug Use and Health, 3.0% met criteria for OUD, and 9% reported prescription pain-medication misuse, while a separate analysis of adult cancer survivors in the United States found OUD prevalence generally below 1%, rising to 1.4% in head and neck cancer survivors.^23,24 Among patients on long-term opioids, roughly 8%–12% develop OUD, and 21%– 29% develop opioid misuse. Further, a 2024 meta-analysis of patients with cancer pooled the opioid-misuse-risk prevalence at 12.3%.^25,26 Most strikingly, in a prospective United States cohort of patients already receiving opioids for cancer pain, 19% developed non-medical opioid use behavior within a median of 8 weeks of their initial supportive care consultation.²⁷

OUD is not solely a problem of patients with pre-existing addiction. Prolonged, high-dose opioid exposure can precipitate OUD in patients with no prior substance use, and poorly treated pain is itself a powerful trigger for misuse or return to use.²⁸ The patients most vulnerable to co-occurring OUD—those with psychiatric illness — are also the least likely to be adequately screened for it.²¹

Consensus on Management

Full-agonist opioids remain the cornerstone of cancer pain management, yet the literature offers limited guidance on managing pain in patients with OUD, two modified Delphi panels of palliative care and addiction specialists were convened to fill the void.^25,28 Several themes emerged with clear agreement:

• Untreated OUD: Regardless of prognosis, initiating buprenorphine/naloxone was appropriate, whereas methadone-clinic referral was inappropriate—too burdensome for seriously ill patients and fragmenting care.²⁸
• Established on buprenorphine/naloxone: Continue it; adding a full-agonist for analgesia was appropriate for a prognosis of weeks to months but uncertain for months to years.²⁵
• Established on clinic methadone: Taking over prescribing with split dosing was appropriate.
• Misuse without definitive OUD: Increase monitoring while avoiding tapering or rotation to buprenorphine/naloxone—balancing risk mitigation against adequate pain control.²⁸

The question for our community is not whether opioids are indicated. It is whether pain medicine leaders will help redesign how cancer pain is identified, triaged, and managed across urban and rural health systems.

These findings are reflected in the 2026 NCCN Adult Cancer Pain guidelines, which state buprenorphine may be a first-line opioid for cancer pain in patients with OUD and should be continued—not stopped—on admission, as discontinuation carries an approximately 50% relapse risk (National Comprehensive Cancer Network, Adult Cancer Pain, 2026).⁸ Buprenorphine offers a ceiling effect for respiratory depression, lower misuse potential, less constipation, and no renal dose adjustment; methadone remains a useful dual-purpose analgesic but demands caution given its variable half-life, QTc effects, and drug interactions. Removal of the X-waiver in 2023 eliminated the principal regulatory barrier to buprenorphine prescribing.

From Consensus to Implementation

For the first time, expert consensus and NCCN guidance provide actionable direction. Both conditions must be managed concurrently even in patients with short prognoses; yet most cancer hospitals do not offer OUD treatment, and referral to outside prescribers fragments care. ^8,28 The remaining challenge is not what to do, but where and how, and, as the next section shows, there is a compelling financial case for building the delivery infrastructure this requires.

The Business Case That Health Systems Are Missing

Symptom management among patients with cancer is a cost-reduction strategy. The PRO-TECT trial (Patient-Reported Outcomes To Enhance Cancer Treatment; Alliance AFT-39; NCT03249090), conducted across 52 United States oncology practices with 1,191 patients, demonstrated that weekly electronic patient-reported outcome (PRO) symptom monitoring reduced emergency visits (HR 0.84) and delayed deterioration of physical function (median 12.6 vs 8.5 months).²⁹ The E2C2 trial (Enhanced, Electronic Health Record–Facilitated Cancer Symptom Control; NCT03892967) showed that collaborative care added to electronic PRO surveillance reduced hospitalizations, emergency department visits, and intensive care unit admissions by 56%–62%.³⁰ In the E2C2 breast cancer analysis, patients receiving the intervention completed significantly more chemotherapy cycles (84% vs 78% completing ≥4 cycles).³⁰ A systematic review and meta-analysis of 69 randomized trials comprising 44,030 patients confirmed that patient-reported symptom burden — including pain (HR 1.07; 95% CI, 1.04–1.11) — independently predicts overall survival.³¹ An Australian social return-on-investment analysis found $9 in social return for every $1 invested in supportive care.³²

A Leadership Opportunity: Comprehensive Interventional Pain Medicine as the Bridge

Despite growing recognition of OUD among patients with cancer, most health systems remain poorly equipped to provide integrated care.^8,33,34 Only 45.5% of United States cancer centers offer chemical dependency services.³³ At an NCI-designated cancer center, 85.9% of clinicians had encountered patients with substance use disorder in the prior year. Yet, only 35% felt confident screening for it, and 61% rarely or never referred for substance use disorder assessment.³⁵ The NCCN states directly that the majority of cancer hospitals do not offer treatment for OUD, and referral to methadone clinics often fragments care. These findings reinforce that the challenge is not simply choosing the right opioid; it is building care models that reduce suffering while minimizing opioid-related harm. Specialists in regional anesthesia and interventional pain medicine offer a distinctive combination of opioid-sparing procedures, expertise in analgesic pharmacotherapy, and longitudinal pain management that complements oncology and palliative care.

The NCCN guidelines list major indications for interventional pain management referral: pain amenable to nerve block, inability to achieve adequate analgesia with tolerable side effects, and — critically — the desire to avoid or limit systemic opioid administration in the setting of regional pain. A Dana-Farber pilot study demonstrated that systematic referral to interventional pain management was feasible, with 57% of patients receiving a procedure and median pain relief of 65%.^36-38 For patients with co-occurring OUD and cancer pain, interventional strategies offer a unique advantage: They can provide meaningful analgesia while reducing or eliminating the need for systemic opioids that carry the highest risk for this population. Celiac plexus neurolysis, superior hypogastric plexus block, intrathecal drug delivery, vertebral augmentation, and neurostimulation are not last-resort options — they are opioid-sparing tools that should be integrated early when appropriate.

Interventional care alone, however, is insufficient. Buprenorphine has emerged as a preferred opioid for cancer pain in patients with OUD, offering analgesia comparable to full agonists with a ceiling effect for respiratory depression, lower misuse potential, and less constipation. The NCCN states that buprenorphine may be considered a first-line opioid for cancer pain management in patients with OUD, and buprenorphine should be continued rather than stopped when such patients are admitted or seen in clinic. With the removal of the X-waiver requirement, the limiting factor is no longer the principal barrier. The remaining challenge is implementation: developing accessible care pathways that integrate Buprenorphine, interventional pain therapies, behavioral health, and supportive services into routine oncology practice. Pain medicine specialists are well positioned to partner with oncology teams to design and deliver integrated care pathways that combine buprenorphine, interventional therapies, behavioral health, and supportive care.

The Pertinence of Opioid Therapy in Cancer Pain Management

Opioids are still indicated for cancer pain. Buprenorphine is a preferred and underused opioid when OUD is a comorbidity in a patient with cancer pain. Health care delivery systems must support programs that assess symptoms, identify OUD, deliver wraparound services, and integrate interventional strategies; largely, these do not exist in most cancer clinics. The evidence base for what works—collaborative care, PRO surveillance, buprenorphine integration, and early interventional referral— is strong. The gap is implementation, workforce training, and institutional will.

The question for our community is not whether opioids are indicated. It is whether pain medicine leaders will help redesign how cancer pain is identified, triaged, and managed across urban and rural health systems, integrating opioid stewardship, interventional therapies, and multidisciplinary care into coordinated care pathways.

References

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